Last year I co-authored a book chapter with Donald Dutton, entitled Treating Assaultive Men from an Attachment Perspective (Dutton and Sonkin, 2003). This chapter was excerpted in The Therapist, September/October, 2003. In it we gave an overview of domestic violence and attachment theory, explored our rationale and clinical approach to treating perpetrators from this developmental perspective. In this article, I would like to speak about attachment theory and its application to psychotherapy in general. I will first begin with an overview of attachment theory and the assessment of attachment status. Then, I will discuss other contemporary authors who are exploring the clinical aspects of attachment theory. The article will finish with how I believe attachment theory may inform our understanding and development of the therapeutic alliance.

Attachment Theory: An Overview

John Bowlby used the term "attachment" to describe the affective bond that develops between an infant and a primary caregiver. He believed that the "attachment behavioral system" was one of four behavioral systems that are innate and evolutionarily function to assure survival of the species. The quality of attachment evolves over time as the infant interacts with his/her caregivers. The type of attachment, or attachment status of the infant toward the caregiver is partly determined by the interaction between the two and partly by the state-of-mind of attachment (vis a vis their own attachment figures) of the caregiver. In his ground-breaking three volumes on attachment and loss (Bowlby, 1969, 1973, 1980), Bowlby wrote that attachment bonds have four defining features: proximity maintenance (wanting to be physically close to the attachment figure), separation distress, safe haven (retreating to caregiver when sensing danger or feeling anxious), and secure base (exploration of the world knowing that the attachment figure will protect the infant from danger). Attachment relationships evolve over the first two years of life and beyond, but most importantly these early attachment relationships overlap with a time of significant neurological development of the brain. (For more information about the neurobiology of attachment, see Siegel (1999) and Schore (2003)). Bowlby describes a series of stages that attachment develops: preattachment, attachment in the making, clear-cut attachment and goal corrected partnership. In the Handbook of Attachment (1999), Cindy Hazan and Debra Zeifman take these stages and apply them to the development of adult pair bonds.

Alan Sroufe (1995), of the University of Minnesota, conceptualizes attachment as a form of dyadic emotion regulation. Infants are not capable of regulating their own emotions and arousal and therefore require the assistance of their caregiver in this process. How the infant ultimately learns how to regulate his/her emotions will depend heavily on how the caregiver(s) regulates his/her own emotions. In fact, the research has shown that there is a very high correlation between the caregiver's attachment status and the attachment status of the infant with that particular caregiver. As children become better at expressing their needs and emotions, they learn self-regulation skills. However, this dyadic regulation never entirely disappears. There is a time for both types of regulation (self and dyadic) throughout a person's life.

Attachment is not a one-way street. As the caregiver affects the infant, the child also affects the caregiver. Edward Tronick (1989) of the University of Massachusetts, refers to this process as "mutual regulation." Daniel Stern, author of the Interpersonal World of the Infant, (1985) refers to the "attunement" of the caregiver: where the parent is sensitive to the verbal and non-verbal cues of the child, and is able to put himself/herself into the mind of the child. Each of these writers view attachment as central to the capacity of emotion regulation.

Mary Ainsworth was the American psychologist who brought Bowlby's theory to the United States and developed a method of assessing infant attachment. In her landmark book, Patterns of Attachment: A psychological study of the strange situation (1978), she describes this widely used protocol, the strange situation, and the patterns of secure and insecure attachment. Originally three patterns were observed, secure, anxious avoidant, and anxious ambivalent, but later on Mary Main and Judith Solomon at the University of California in Berkeley described a fourth category, disorganized (1986). The anxious-avoidant and disorganized types sought attachment but experienced anxiety as a consequence of attachment. Also, both experienced anxiety at the disappearance of the mother and were difficult to soothe upon reunion. The disorganized children were particularly ambivalent upon reunion with their attachment figure, both approaching and avoiding contact. Bowlby, in his book Attachment and Loss, (1969) described these children as "arching away angrily while simultaneously seeking proximity" when re-introduced to their mothers. Interestingly, although the anxious-avoidant children seemed content in the absence of their attachment figure and not particularly interested in reconnecting upon reunion, when physiological measures were taken, these children were quite anxious during separation, but somehow learned to repress their feelings.

In the 1980s, the field of adult attachment began to evolve. This occurred for several reasons. First, many attachment labs, such as the one at the State University of New York at Stony Brook, were conducting research on the continuity over time of attachment status, and long term effects of secure and insecure attachment (Waters, Merrick, Treboux, Crowell, and Albersheim, 2000). As the children assessed in the strange situation (at ages 12 or 18 months) grew up, data on the continuity of attachment patterns began to emerge. In addition, social psychologists such as Phil Shaver at the University of California in Davis, and clinical researchers Phil and Carolyn Cowan at UC Berkeley, became interested in attachment in adult relationships. For example, the Cowans (1999) have extensively studied the transition to parenthood and how attachment status affects the process. Phil Shaver was one of the first researchers to study how attachment status affects the dynamics of couple's relationships (Hazen and Shaver, 1987). More recently, he along with Mario Mikulincer from the Department of Psychology at Bar-Ilan University in Israel, has studied the effects of secure-base priming with insecure individuals on their prejudices and perceptions of people who do not belong to their ethnic group (Mikulincer & Shaver, 2001). The terminology of adult attachment is somewhat different from infant attachment. Secure children are referred to as secure or autonomous adults. Anxious-avoidant children are referred to as dismissing adults. Anxious ambivalent children are referred to as preoccupied adults. Disorganized children are referred to as disorganized or unresolved adults. There is also a category of children and adults, referred to as "cannot classify" because particular patterns do not emerge in their assessment. This represents a very small percentage of the population.

Three important findings have emerged from the research in adult attachment. First, is that the attachment status of a prospective parent will predict the attachment status of their child to that parent: with as high as 80 percent predictability (van Ijzendoorn, 1995). Second, although changes over time can influence the attachment status of a child, there is a strong continuity between infant attachment patterns, child and adolescent patterns and adult attachment patterns. Changes in attachment status can occur in either direction (secure to insecure, insecure to secure), and in fact, the term "earned secure" has been used to describe individuals who experience malevolent parenting (and therefore one would expect an insecure attachment status), but have risen above those experiences and who are assessed as securely attached (Main and Goldwyn, 1993). However, for the majority of individuals, the manner in which they learned to manage anxiety early on in life will continue unless their circumstances change or other experiences intervene. For many people, the coping mechanisms may become more sophisticated, but the net result (over-activating or under-activating in the case of insecure attachment, and modulation with secure attachment) will essentially continue. Lastly, adults assessed as having an insecure state-of-mind with regard to attachment have greater difficulties in managing the vicissitudes of life generally, and interpersonal relationships specifically, than those assessed as securely attached (Shaver and Mikulincer, 2002).

Assessing Attachment

There are two general methods for assessing attachment in adults, interview methods and self-report scales. The most common interview method is the Adult Attachment Interview (AAI) developed by Mary Main and her colleagues at the University of California at Berkeley (Main and Goldwyn, 1993). The Adult Attachment Interview contains 20-questions that asks the subject about his/her experiences with parents and other attachment figures, significant losses and trauma and if relevant, experiences with their own children. The interview takes approximately 60-90 minutes. It is then transcribed and scored by a trained person (two weeks of intensive training followed by 18 months of reliability testing). The scoring process is quite complicated, generally but it involves assessing the coherence of the subject's narrative. Mary Main describes a coherent interview in the following way.

"...a coherent interview is both believable and true to the listener; in a coherent interview, the events and affects intrinsic to early relationships are conveyed without distortion, contradiction or derailment of discourse. The subject collaborates with the interviewer, clarifying his or her meaning, and working to make sure he or she is understood. Such a subject is thinking as the interview proceeds, and is aware of thinking with and communicating to another; thus coherence and collaboration are inherently inter-twined and interrelated" (Slade, 1999, page 580).

Some sample questions from the AAI are:

I'd like you to choose five adjectives that reflect your childhood relationship with your mother. This might take some time, and then I'm going to ask you why you chose them. (Repeated for father)

To which parent did you feel closest and why? Why isn't there this feeling with the other parent?

When you were upset as a child, what would you do?

What is the first time you remember being separated from your parents? How did you and they respond?

What is it about the coherence of a life story that reflects the attachment status of the subject? There are differing ideas for this, but what seems like the most plausible explanation to this writer is, when telling one's life story, it is likely to generate subtle and not so subtle emotions about those experiences. How one regulates those emotions is going to, in part, determine the way the story is told. Reading the transcripts of securely attached individuals, their stories are coherent in the manner Main described above. Dismissing adults tend to have extremely brief stories. Many don't recall memories of childhood. Those who have untoward experiences either deny their occurrence or rationalize their negative feelings and claim that those experiences made them stronger and more independent. Preoccupied individuals tend to get caught up in negative, analytic discussions of their past and therefore their transcripts tend to be excessively long. Their past tends to intrude on their present discussions of attachment and can be extremely devaluing or idealizing of their attachment figures. Their narratives are entangled and hard to follow. Disorganized individuals tend to have lapses in the monitoring of reasoning and discourse in their interview when discussing loss or experiences with abuse (Hesse, 1999). The AAI protocol is available at the Stony Brook Attachment Lab web site at:

Another method similar to the AAI was developed by Peter Fonagy and Mary Target of the Psychoanalysis Unit of University College, London. They use the AAI questions, but the transcript is analyzed from from the perspective of Òreflective function.Ó Scoring the narrative involves assessing the speaker's ability to reflect on their own inner experience, and at the same time, reflect on the mind of others (Fonagy and Target, 1997).

Another promising method of assessing adult attachment is the Adult Attachment Projective (AAP) developed by Carol George of Mills College, and Malcolm West of the University of Calgary (George and West, 2001). The test consists of eight drawings (one neutral scene and seven scenes of attachment situations). According to the authors, "the drawings were carefully selected from a large pool of pictures drawn from such diverse sources as children's literature, psychology text books, and photography anthologies. The AAP drawings depict events that, according to theory, activate attachment, for example, illness, solitude, separation, and abuse. The drawings contain only sufficient detail to identify an event; strong facial expressions and other potentially biasing details are absent. The characters depicted in the drawings are culturally and gender representative" (page 31).

Like the AAI, the subject's responses are recorded and transcribed and then scored based on the coherence of the responses. Authors use some similar and different scales from the AAI coding process. According to the authors the AAP takes less time to administer and much less time to score, which makes it more useful for clinicians. Unlike the AAI, the AAP is geared toward clinicians as opposed to only researchers in attachment. For more information on the AAP see their web site at http: //www.attachmentprojective.com/.

The other method of assessing adult attachment is with self-report scales. The Experiences in Close Relationships Scale: Revised, developed by Phillip Shaver and his colleagues (Brennan, Clark and Shaver, 1998), is a self report scale that measures attachment security on two dimensions, anxiety and avoidance. The first scale developed had three questions. Since then, it has been expanded to 36 questions. Their most recent version was based on a scale developed by Kim Bartholomew: the Relationship Status Questionnaire (Bartholomew and Horowitz, 1991). Because they have many of the same items, these two scales correlate highly with one another (Shaver, Belsky and Brennan, 2000). One important difference between their two scales is in how they deconstruct attachment. Shaver and his colleagues view attachment on two continuums, anxiety and avoidance. How an individual scores on each of these subscales will determine their attachment classification. Bartholomew, on the other hand, deconstructs attachment also on two continuums: working models of self and others (either positive or negative) (Bartholomew and Moretti, 2002). Her approach was more in line with Bowlby's initial cognitive conceptualization of attachment. However, what these two tests reveal is that the cognitive (Relationship Status Questionnaire) and emotional/behavioral (Experiences in Close Relationships Questionnaire) dimensions are all linked with regard to attachment. The advantage of these self-report scales is that they are easy to administer and score, and therefore clinicians do not need special training in their use.

Can attachment status be assessed via a clinical interview? Unfortunately, clinicians are not as accurate as they would like to think they are. And the studies of comparing clinician's diagnostic abilities and psychometric testing support this contention. But it is my belief that as a clinician gets to know his/her client's over time, and carefully observe their behaviors and listen to their language, attachment patterns begin to emerge and can be clearly recognizable. However, this takes time and good observation on behalf of the clinician. So in the meantime, using one of the available methods of assessing attachment status is worthwhile.

Attachment and Psychotherapy

Over the past ten years, a number of individuals have begun to explore how this body of knowledge of attachment theory would apply to clinical practice. A number of these writers bear mentioning. Peter Fonagy, of the Psychoanalysis Unit of the University College London, has written two ground-breaking books on integration of attachment theory and psychotherapy: Attachment Theory and Psychoanalysis (2001) and Affect Regulation, Mentalization and the Development of the Self (with M. Target, G. Gergely and E.J. Jurist) (2002). In his books, Fonagy speaks about the hallmark of secure attachment being the ability to reflect on one's internal emotional experience, and make sense of it, and at the same time reflect on the mind of another. One can immediately see how these capacities are imbued in the infant through sensitive attunement of the caregiver. When a caregiver reads the verbal and non-verbal cues of the child and reflects them back, the child sees him or herself through the eyes of the attachment figure. It is through this attunement and contingent communication process that the seeds of the developing self are planted and realized. Insecurely attached individuals lack this reflective function either because their emotional responses are so repressed as in the case of the dismissing attachment status or exacerbated as in the case of the preoccupied attachment status that they are unable to either identify their own internal experience or reflect on that of the other. When either one of these extremes are the method of regulating the attachment behavioral system, the capacity for reflection (on oneself and others) is compromised.

Jeremy Holmes, likewise an analyst in England, has written the book The Search for the Secure Base: Attachment Theory and Psychotherapy (2001). Holmes talks at great length about the narratives of insecurely attached individuals. He refers to story-making, and story-breaking. In the case of dismissing attachment, where the story is so restricted as to reduce the possibility of dysphoric affect, the clinician is helping the patient create a story that is coherent, full of memory and manageable affect. In the case of preoccupied attachment, where anxiety over-runs the client's story in that it becomes convoluted and saturated with anger and disappointment, the therapist's role is to help break the negative cycle of the narrative, manage the affect more effectively and create a story that is balanced and coherent.

Allen Schore's two most recent books, Affect Dysregulation and Disorders of the Self, and Affect Regulation and Repair of the Self (2003) goes beyond integration of developmental theory and psychotherapy, but also describes the neuroscience of attachment and how the brain of the parent and infant interact. Schore speaks in depth about the neurobiology of the developing mind during the first three years of life and how the right brain processes are integrally involved in attachments and the development of the self. He spells out very clearly how insensitive parenting leads to emotion dysregulation patterns in childhood and later in adulthood. He understands insecure attachment as emotion dysregulation and therefore the goal of psychotherapy is to learn new capacities to manage attachment distress: that psychotherapy is the process of changing neural patterns in the brain, the right brain in particular.

Daniel Siegel writes in his book, The Developing Mind: How Relationships and the Brain Interact to Shape Who We Are (2001), like Schore, he has expanded our understanding of how attachment relationships and the brain influence each other respectively. Siegel is particularly interested in how the right and left brain work together (or don't in the case of insecure attachment) to create a coherent life story and way of responding to relationships and life. He takes complexity theory and applies this to psychological functioning. Complex systems are the most adaptive and stable, whereas rigid systems are not. His book not only focuses on attachment, but other related topics such as emotion, memory, trauma, and consciousness. He draws from multiple disciplines to help the reader understand that no one focus of study, such as psychology, will have all the answers to important questions, such as "what is mental health?"

Each of these authors has expanded our understanding of how to incorporate the vast body of knowledge that has accumulated in attachment theory into the practice of psychotherapy. However, many questions remain unanswered and therefore we are just beginning to understand this interface. Arietta Slade, of the Department of Psychology at the City University of New York (1999), sums up the controversy of whether or not attachment theory is relevant to clinical practice by stating, "In essence, attachment categories do tell a story. They tell a story about how emotion has been regulated, what experiences have been allowed into consciousness, and to what degree an individual has been able to make meaning of his or her primary relationships" (p. 585).

If one way of conceptualizing attachment status is that it is a form of affect regulation that occurs in the context of relationships in general, and how individuals deal with emotions associated with separation, loss and reunion specifically, it seems that attachment theory would be relevant to one of the most significant areas affecting the work of psychotherapists: the therapeutic alliance.

The Therapist as an Attachment Figure

Bowlby believed that intimate attachment to other human beings are the hub around which a person's life revolves (1969). From these intimate attachments a person draws his strength and enjoyment of life. He also believed that one such attachment may be a person's therapist. Bowlby describes the five tasks of attachment informed psychotherapy in his book, A Secure Base (1998). One of those tasks is to explore the relationship with a psychotherapist as an attachment figure. Bowlby believed that the therapist would be viewed as an attachment figure regardless of whether or not the client is aware of this fact. The therapist-client relationship, like the parent-child relationship will manifest the same four characteristics described earlier: proximity maintenance (the client will seek the therapist to discuss problems), separation distress (the client will experience some degree of distress when needing the therapist and the therapist is not available), safe haven (will seek the therapist when needing help in resolving distress), and secure base (will use the therapist as a secure base to explore the inner and outer worlds of her/his life). Like the process of developing attachment that occurs in the child-parent relationship, the developing of the therapeutic relationship will follow a similar process: preattachment, attachment in the making, clear-cut attachment and goal corrected partnership. And like the patterns of attachment that emerged in the stressful Strange Situation Procedure, the natural ruptures and reunions that occur in the psychotherapy are likely to activate the attachment behavioral system. For some individuals who have had particularly untoward experiences in their family of origins, simply walking into the therapist's office is likely to cause anxiety. But in this unusual type of relationship, the client has the opportunity to have these patterns brought to their attention, reappraise their functionality and learn new methods of regulating affect.

But how does one actually facilitate this process? Siegel (1991), among other things, writes about the non-verbal communication of primary emotions and the importance of contingent communication between therapist and client. Contingent communication begins when Person A sends a signal to Person B: these signals are both verbal and non-verbal signals (facial expressions, body movements/gestures, tone of voice, timing and intensity of response, etc.). Person B needs to recognize the signal, interpret it correctly and send back a signal to Person A. Now this response is not just simply a mirror of what was received, but Person B sends a message that the original signal was received, interpreted and is being responded to by the receiver: in other words "I got it." When this occurs, the sender feels felt or understood and then the process continues. Siegel contends that contingent communication is the basis of healthy, collaborative communication and facilitates positive attachments.

In psychotherapy, most communication between the therapist and patient occurs on this non-verbal level. The role of the therapist is to watch for non-verbal signals (a right brain to right brain process) and work to interpret them and respond to them appropriately. This seems so elementary and each of us probably remembers a talk in graduate school about the value of non-verbal communication. Yet, if what these writers are telling us is true, then it seems that the ability to read and interpret these non-verbal signals is more than a therapeutic trick we occasionally pull out of our bag. It is the basis of developing the therapeutic alliance, which in turn is the key to positive therapy outcome.

Daniel Stern refers to talks about the significance of "now moments" (2004). These are flashes of interactions between the therapist and the client that are rich in potential for change and growth in the client, but also in the therapist and the relationship as well. Stern describes the process of therapy as moving along in a somewhat spontaneous and sometimes random manner until these moments occur. I think about the time when I was sitting in the car with my then one-year-old daughter and we were playing with a box. All of a sudden the top fell off and multicolored glitter spilled all over her lap, my lap and the back seat. We looked at each other intently and then at the exact same moment we both burst out into laughter. This is when a now moment is turned into a "moment of meeting." In that moment there is a deep sense of connection and intimacy. For individuals in psychotherapy who do not experience those moments, for the most part in their relationships are missing something important indeed. When "now moments" are recognized in the context of the psychotherapy, there is the potential for a deep connection between the participants, and as the studies have indicated, this is a necessary ingredient for positive therapeutic outcome.

In my work with patients, I likewise try to both keenly attune myself to the client's signals, both verbal and nonverbal, and at the same time attune myself to my own internal experience. Like the mutual regulation that occurs between parent and child, a similar process is occurring in the therapeutic relationship. Subtle nonverbal cues are picked up and processed by the mind, under the radar so to speak, but a reaction occurs nevertheless. This is why it is so important for therapists to be attuned to their own internal emotional/body experience and be able to represent it in their minds. Likewise, changes in the therapist's state-of-mind will be picked up by the client and will either exacerbate or reduce their anxiety. This close attention to the process of contingency is critical to the development of the therapeutic relationship. When a patient feels by the other, they experience a deep sense of being understood, which contributes to positive feelings associated with close relationships.

The other important aspect of this process is the therapist's state of mind with regard to attachment will not only be a critical factor in both the development of the alliance, but also in the ultimate outcome of psychotherapy. The research suggests attunement, or this contingent communication described above, accounts for about 50 percent of the transmission of attachment status from parent to child (Siegel, 1999). You can train parents to be more attuned to their children and this will enhance attachment security with the children and the transmission rate is about 50 percent (Van IJzendoorn, Juffer & Duyvesteyn, 1995). Yet the general studies on the generational transmission of attachment consistently suggest that the actual rate of transmission from parent to child is about 80 percent. So what accounts for this 30 percent transmission gap? It has been suggested by these writers, that perhaps there is something about the way the brain communicates with other brains during early development in particular that allows for such a significant transmission rate.

We know that securely attached adults "do" certain things with their infants that result in attachment security in their children. This is often termed parental attunement or sensitivity. Yet these actions do not account for all the transmission factors. Don't forget, early in the first three years of life, the brain is still exponentially developing, particularly in the frontal lobes: the part of the brain that plays an important role in attachment related capacities. Perhaps it is something about the way our brains communicate with one another. The organization of the parent's brain (whether secure or insecure) plays a significant part in the organization of the developing brain of the child. You may be thinking "this guy is getting way out there." But this type of thinking is now being discussed in neurobiology circles. Scientists who in the past were not interested in the brain and interpersonal relationships are now getting very interested in this process. So like most things in our profession, there are more questions than answers, but it is important for therapists to ask these questions and expand our understanding of this phenomenon. What does this mean to psychotherapy? Simply stated, the more integrated and aware the therapist is of her/his own state of mind, the greater he/she will be able to help his/her patients achieve integration and awareness. From an attachment point of view, the more secure the therapists, the greater they can imbue security in their patients. This is why I suggest that all therapists take an attachment questionnaire and discover what their own strengths and vulnerabilities might be with regard to attachment status.